September 2017

Provincial Redistribution Update:

Change is afoot!

By: Tracy Cameron, Regional Project Coordinator, ORBCoN

With the growing anticipation of Canadian Blood Services (CBS) implementation of new insulated shipping containers (ICSs), Ontario hospitals are getting ready for a big change in how they ship components and products between sites as well as transport to the emergency rooms and operating suites.

CBS announced in early 2015 that they would be implementing new ICSs that would include a single packing configuration suitable for all seasons, allowing a greater number of products to be shipped to hospitals and eliminate the use of dry ice as a refrigerant for frozen products. But with the new ISCs comes a restriction for hospitals not to use them for redistribution or transfer of product, since the preconditioning of the plates used to maintain the temperature within the shipping container is a two stage process and requires specialized equipment. Hospitals are being asked to continue to use the J82 shipping containers to ship red blood cells (RBCs) and refrigerated blood products, as well as the E38 shipping containers to ship platelets and room temperature blood products for the purpose of redistribution, transport to other patient care areas, and for products transferred with a patient to external facilities. These containers will continue to be supplied by CBS and hospitals will be able to order them similar to placing an order for products. However the validation of these boxes will not be supported by CBS any longer.

What can hospitals expect for the redistribution program and transferring components and products with a patient?

ORBCoN has partnered with two hospitals to validate the J82 and E38 shipping containers at different temperature points that mimic possible ambient temperature conditions during transportation. The containers are being challenged at extreme warm temperatures (35 to 40°C), room temperature (19 to 25°C), mild temperatures (1 to 6°C) and extreme cold temperatures (-30 to -35°C). The data collected will determine how long the shipping containers can maintain the required acceptable temperatures for shipping components and products with a minimal payload and a maximum payload.

During the validation, questions arose regarding the packing configuration of the J82 containers and how hospitals currently precondition the ice packs for the container. In 2016 we asked hospitals what temperature freezer they had available and 59% of the hospitals responded saying they currently use a freezer with temperatures as cold as -40°C. Most hospitals were preconditioning freezer packs between -25 and -40°C. In a more recent survey we asked hospitals if they had access to a freezer with temperatures between -25 and -40°C and if they had room in their freezer for ice packs for preconditioning. Table 1 shows the results from the survey. The data justified keeping the packing configuration protocol to just preconditioning ice packs between -25 and -40°C and not expand the validation to include preconditioning ice packs in warmer freezers (-18 to -22°C). Hospitals wishing to participate in the redistribution program must meet the requirements of freezer temperature and size capacity to precondition ice packs.

The original CBS packing configuration for the J82 container required 2 ice packs to be preconditioned between -11 and -14°C for the products to maintain the required acceptable temperature for up to 24 hours. This packing configuration will be changing slightly to using only one freezer pack preconditioned between -25 and -40°C for at least 6 hours prior to use. This, along with a few other minor changes to the packing configuration, will be provided in an updated Provincial Redistribution Toolkit that is currently being revised by a provincial working group.

What can you expect to find in this toolkit?

The working group is revising operating procedure templates for the redistribution of fresh components as well as the redistribution of blood products using the J82 and E38 shipping containers. The operating procedure for the Golden Hour containers will also be updated and included. The toolkit will include a standardized inter-hospital transfer form that is to be used when redistributing any products as well as a new memorandum of understanding (MOU) for hospitals that are participating in the redistribution program. Revisions are also underway for the operating procedure template for transferring blood components and products with a patient to an external facility. A training package is being developed to help lab staff become familiar and competent with the revised redistribution process. The target date for the release of the toolkit is late October early November 2017.

Redistribution of frozen products may not be an option for some hospitals that do not have access to dry ice. CBS will phase out the use of dry ice to ship frozen products, and hospitals will have to use their own supply if they want to continue to redistribute frozen products. The working group recognizes this issue and ORBCoN and CBS have been notifying hospitals during site visits.

Blood Products and Critical Care

Transport in Ontario

Ornge is the air medical and land critical care transport agency in the Province of Ontario. Using its fixed wing aircraft, helicopters, and land-based critical care transport vehicles, Ornge carries out approximately 20,000 patient transports each year, making it Canada’s largest critical care transport service. Advanced and critical care paramedics are highly skilled providers and function under a ‘delegated acts model’, under the auspices of a dedicated transport medicine physician. The paramedic scope makes it possible for them to provide care comparable to that in an intensive care unit.

Ornge is a key stakeholder in Ontario’s regionalized health care system, enabling patients to access specialized or tertiary care services in a timely manner. Most patient transports take place between two hospitals, referred to as ‘inter-facility’. Ornge’s helicopters also respond to ‘scene calls’, where the helicopter lands at the roadside, in a farmer’s field, or some remote location, to transport patients with acute life-threatening injury or illness directly from the scene to a hospital. For many, particularly in northern Ontario, Ornge is the only access to definitive care due to distance or lack of road access in remote communities.

In 2016, Ornge delivered 570 units of blood product to 335 patients. Common indications include hemorrhagic shock in trauma, post-partum hemorrhage, gastrointestinal bleeding, and hematologic malignancies. Ornge aircraft and crews do not carry blood products. Ornge acquires blood products from the sending facility, and administers them in partnership with sending facility staff. Ornge adopted Sunnybrook Health Sciences Centre’s practices for blood product administration, and modified them to meet the transport environment. All blood product administration requires an order from the Ornge transport medicine physician. The lack of blood products in many locations Ornge services poses a unique challenge to meet patient care needs. The longest transports occur in Northern Ontario, and the north accounts for a disproportionate number of calls. Many northern hospitals have limited or no blood product, and nursing stations do not have any. Each week, there are one or two patients that Ornge transports who meet indications for time-sensitive blood product administration, but no blood product is available.

Ornge carried out an environmental scan of Canadian critical care transport agencies to identify how they access blood products. In four provinces, transport agencies partnered with Canadian Blood Services to make blood product available at the transport agency’s bases, or accessible from a central blood bank in a timely manner.

Ornge’s Medical Director met with the Ontario Regional Blood Coordinating Network in June to discuss a partnership to develop an information exchange system to enhance traceability of all blood products administered by Ornge’s paramedics, and to develop ways to make blood products available at Ornge’s bases in northern Ontario. The partnership is in its infancy, with goals of meeting patient care needs and enhancing accountability for blood product used in delivery of care. For more information about Ornge or this initiative, please contact Troy Thompson (troy.thompson@sunnybrook.ca) or Dr. Russell MacDonald (rmacdonald@ornge.ca).